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High prevalence of stockouts of antiretroviral medicines in South Africa

One in five public health
facilities in South Africa were unable to supply at least one antiretroviral (ARV)
or tuberculosis (TB) drug on the
day they were contacted by researchers, while over a third had had a drug
stockout in the previous three months, according to a national survey published
in PLOS ONE.

Between October and December 2015,
the survey investigators contacted facilities by telephone
to enquire about stockouts, which they defined as “a complete absence of a
specific formulation and/or dosage of medicine at a given facility”.

Of the 2370 surveyed health
facilities providing ARVs and TB medicines, 20% (485) reported a stockout of at
least one ARV or TB-related medicine on the day of contact, while 36% (864)
reported the same in the preceding three months. There were significant
discrepancies from one province to another – for example, 74% of facilities in
Mpumalanga reported stockouts in the past three months, compared to 12% in the
Western Cape.

The physical form in which a drug is manufactured or administered. Examples of formulations include tablets, capsules, powders, and oral and injectable solutions. A drug may be available in multiple formulations.

During the three months prior to
contact, there were stockouts of the following medicines:

At least one
adult first-line ARV (11% of facilities)

At least one
adult second-line ARV (15%)

At least one
less commonly used ARV (11%)

At least one
paediatric ARV (9%)

Nevirapine syrup
used for the prevention of mother-to-child transmission (1%)

At least one
TB medicine (4%).

A total of 1475 different
stockouts were reported in the previous three months, with between one and
14 medicines out of stock per facility. Of these 1475 stockouts, 73% (1082)
were of ARVs for adults; 18% were of
ARVs for children; 2% were of nevirapine syrup and 7% were of TB-related drugs.

Of the 1082 stockouts of adult ARVs, 29% were used as first-line
treatment, 41% as second-line, and 29% were less commonly used ARVs. The main
driver for the second line ARV stockouts was a national shortage of adult
lopinavir/ritonavir that had been documented.

The investigators also wanted to collect information on how long
stockouts lasted and their impact on patients’ treatment regimens.

For people whose lives depend on treatment, stockouts are unacceptable.
But in this case, their duration was even more so, with 70% of stockouts
lasting for over a month. Also, there were significant discrepancies between
provinces. In the Western Cape, the province with the ‘shortest’ stockouts,
29% lasted less than a week and 33% over a month. In Mpumalanga, 1% lasted less
than a week and 88% continued for more than a month.

The impact of each stockout was classified as high, medium or low by
the authors.

High impact (25% of cases): patients left the
facility without any treatment or with an incomplete regimen.

Medium impact (39%): patients were referred
elsewhere or turned away; received drugs borrowed from another facility;
switched to a less optimal regimen, but not necessarily provided with full
supply of medicines, etc.

Low impact (36%): switched appropriately to a
different regimen, dosage or formulation; a full supply borrowed from another
facility, etc.

The majority of staff who responded to the survey were nurses-in-charge
(58%) and nurses (17%), rather than pharmacists (16%) and pharmacy assistants
(9%). Following the research protocol, the researchers first tried to speak to
pharmacy staff, before turning to nursing staff if they were not available.
Pharmacists are likely to have a better knowledge and recall of stockouts,
whereas nurses may be more aware of treatment switches and the clinical impact.

The survey fills an important gap: according to its authors, the current
South African monitoring system does not provide transparent information on
medicine availability and the true extent of the problem across the country was
not known. The survey may be the first national stockout evaluation conducted
in a resource-limited setting.

It rings alarm bells for South Africa, the nation with the highest
number of people living with HIV and incidence of TB worldwide, a rising
epidemic of multidrug resistant TB and, concomitantly, the world’s most
ambitious antiretroviral treatment programme. But it should also raise concern
among policymakers in other resource-limited countries.

Throughout the article, we are reminded of the terrible consequences of
poor medicines management on people living with HIV: treatment interruptions
due to disengagement from care, poor adherence, emergence of HIV or TB
resistance (sometimes multidrug resistance), financial costs for those who must
travel longer distances to get their medicines, etc. In other words, as a
result of these stockouts, people living with HIV become even more vulnerable
than they already are. For example, the “less commonly used ARVs” stockout rate
of 29% is of particular relevance to those adults who have shown
contraindications or resistance to the more widely prescribed drugs.

The United States said on Wednesday it will provide thousands of doses of HIV medication to treat Venezuelans in Colombia as part of regional efforts to manage care for millions of migrants fleeing the crisis-hit nation.

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